Missouri earns ‘C’ at managing pain, regulating opioids

The General Assembly might make access
to drugs more difficult.
Monday, September 22, 2003 | 12:00 a.m. CDT; updated 12:05 p.m. CDT, Monday, July 7, 2008

Missouri’s policies on pain management meet — but don’t yet beat — the national average, according to a new report from researchers at the University of Wisconsin. But a new council established this year by the Missouri General Assembly could change legislation that hinders patients’ access to drugs for chronic and acute pain.

Missouri earned a “C” overall for its policies on prescribing and regulating opioid drugs to control pain in a state-by-state evaluation that included the District of Columbia. That is up from a “D” in March 2000. No states scored an “A” or “F” overall.

Opioid analgesics were chosen for the study, “Achieving Balance in a State Pain Policy: A Progress Report Card,” because they are a mainstay for treating long-term or severe pain and are needed to maintain public health. Opioid analgesics are controlled substances that include morphine and oxycodone.

Policies in states that received high grades balanced patient access to the drugs with prevention of abuse and addiction, said Aaron Gilson, assistant director of the university’s Pain and Policy Study Group and an author of the report. Right now, “the balance is tipped against patients,” he said.

“Our study is not about making it easier for abusers to get drugs,” Gilson said. “It’s about making it easier for patients to get drugs.”

States were given low grades if their policy language promoted misconceptions about addiction; required government monitoring of patients using the drugs;imposed undue limits on the amount that can be prescribed; or suggested that opioids are a last resort or hasten death.

Missouri was one of only 14 states that improved its overall grade compared to March 2000 grades, which were calculated for comparison. Each grade was divided into two parts — a positive grade for the promotion of pain management and a negative grade for impeding it. But for Missouri, only one, the positive grade, improved.

Gilson said guidelines for the use of controlled substances, adopted in 2001 by Missouri’s Board of Healing Arts, deserved much of the credit for the improvement, raising the positive grade from a C to an A. The board issues licenses to practice medicine in the state, but not to prescribe drugs.

John Heidy, chief investigator of the Board of Healing Arts, said practitioners in the past had been concerned about retaliation from regulatory agencies. But as long as physicians document their reasons for prescribing controlled drugs, they should not have any fears, he said.

Ambiguous or negative statements in relevant state laws landed Missouri an F for negative elements, for a C overall in 2003. The same state laws had received an F in 2000, bringing its composite grade to a D that year.

The researchers faulted Missouri’s Controlled Substances and Intractable Pain Treatment acts for including passages that were ambiguous or were restrictive to doctors and other practitioners who prescribe or recommend drugs.

All that could change soon.

In July, Gov. Bob Holden approved a bill that established the Missouri State Advisory Council on Pain and Symptom Management. The council will recommend acute and chronic pain management practices based on public hearings, review pain-management-education guidelines and practices, and “analyze statutes, rules and regulations relating to pain management,” the Senate Web site said.

Pain management is one of the issues at the forefront of modern health care, said Sen. Charlie Shields, R-St. Joseph. The bill was later passed as part of another House bill. “Missouri did not have anything in our legislature that addressed that,” said Shields, sponsor of the original Senate bill.

The council will also report annually to the governor and can recommend changes in state policy on pain management on a case-by-case basis.

“If the council meets and tells us we need changes, then we’ll move forward,” Shields said.

Although the bill was proposed by the American Cancer Society, the council’s role is not limited to cancer issues.

Gilson was encouraged to hear of the council and its potential for educating the medical community. But he said changing restrictive language in laws could sometimes take a lot of effort.

Kansas was one of just four states with a B-plus, the highest overall grade.

“It’s very easy for states that received a B-plus to get an A simply by removing some restrictive language,” Gilson said.

Iowa earned a B overall, while Illinois received one of the lowest grades, a D-plus.

The report was supported by the Robert Wood Johnson Foundation. It was a “black-letter policy evaluation,” meaning policies are graded solely by their language and not their implied or intended effects, Gilson said.

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